Manning W J, Silverman D I, Keighley C S, Oettgen P, Douglas P S
Charles A. Dana Research Institute, Beth Israel Hospital, Boston, Massachusetts 02215, USA.
J Am Coll Cardiol. 1995 May;25(6):1354-61. doi: 10.1016/0735-1097(94)00560-D.
We sought to validate the safety of transesophageal echocardiographically guided early cardioversion in conjunction with short-term anticoagulation as a strategy for guiding early cardioversion in hospitalized patients with atrial fibrillation.
Because atrial thrombi are poorly seen by conventional imaging techniques, several weeks of prophylactic anticoagulation is routinely prescribed before cardioversion. Transesophageal echocardiography is a superior test for identifying atrial thrombi; preliminary feasibility studies have supported its use to guide early cardioversion for patients in whom no thrombus is observed, but safety has not been validated in any large series.
All patients admitted to hospital with atrial fibrillation during a 4.5-year period were screened. The inclusion criterion was a clinical duration of atrial fibrillation > 2 days or of unknown duration. Patients received anticoagulation with heparin/warfarin and underwent conventional transthoracic echocardiography followed by transesophageal study. Patients in whom transesophageal echocardiography revealed no atrial thrombus underwent pharmacologic or electrical cardioversion followed by warfarin therapy for 1 month. Cardioversion was deferred in patients with evidence of atrial thrombi, and they received prolonged warfarin treatment.
Two hundred thirty-three patients (86% of those eligible) agreed to participate, and 230 underwent transesophageal echocardiography. Transesophageal echocardiography identified 40 atrial thrombi (left atrium 34, right atrium 6) in 34 patients (15%). One hundred eighty-six (95%) of 196 patients without thrombi had successful cardioversion to sinus rhythm, all without prolonged anticoagulation, and none (0%, 95% confidence interval 0% to 1.6%) experienced a clinical thromboembolic event. Eighteen patients with atrial thrombi underwent uneventful cardioversion after prolonged anticoagulation.
Compared with smaller series that have shown only feasibility, this large prospective and consecutive study of patients undergoing transesophageal echocardiographically facilitated early cardioversion in conjunction with short-term anticoagulation validates the safety of this strategy. This treatment algorithm has a safety profile similar to conventional therapy and minimizes both the period of anticoagulation and the overall duration of atrial fibrillation.
我们试图验证经食管超声心动图引导下早期复律联合短期抗凝作为指导住院房颤患者早期复律策略的安全性。
由于传统成像技术难以发现心房血栓，因此在复律前通常会进行数周的预防性抗凝治疗。经食管超声心动图是识别心房血栓的更佳检查方法；初步可行性研究支持其用于指导未观察到血栓的患者进行早期复律，但尚未在任何大型系列研究中验证其安全性。
对4.5年期间入院的所有房颤患者进行筛查。纳入标准为房颤临床持续时间>2天或持续时间不明。患者接受肝素/华法林抗凝治疗，并先进行常规经胸超声心动图检查，随后进行经食管超声心动图检查。经食管超声心动图未发现心房血栓的患者接受药物或电复律，随后进行1个月的华法林治疗。有心房血栓证据的患者推迟复律，并接受延长的华法林治疗。
233例患者（占符合条件者的86%）同意参与，230例接受了经食管超声心动图检查。经食管超声心动图在34例患者（15%）中发现了40个心房血栓（左心房34个，右心房6个）。196例无血栓患者中有186例（95%）成功复律为窦性心律，均未进行延长抗凝治疗，且无一例（0%，95%置信区间0%至1.6%）发生临床血栓栓塞事件。18例有心房血栓的患者在延长抗凝治疗后顺利复律。
与仅显示可行性的较小系列研究相比，这项对接受经食管超声心动图引导下联合短期抗凝的早期复律患者进行的大型前瞻性连续研究验证了该策略的安全性。这种治疗方案的安全性与传统治疗相似，并将抗凝时间和房颤总持续时间降至最低。
